Integrated Patient Care

When patient care is a priority, there is a natural integration of more and more elements of their hospital experience, from their entry process through their stay, and finally their discharge. Not only is integrating care delivery service more efficient at delivering care—it’s more effective.

An integrated care delivery model starts with the process of admission, then the quick and efficient transfer of the patient, seamless, efficient delivery of care to the patient, and an equally smooth discharge process. The following image demonstrates the key components of this integrated care delivery model.

This all sounds very simple. But in reality, it is quite complex, with a multitude of moving parts, departmental hand- offs, documents to track, and people to keep informed and engaged.

There are a variety of models in existence, each suited to the size, volume, complexity, and infrastructure of different healthcare institutions. We will walk through a model designed for a large multispecialty organization with very high patient volume. These hospitals often depend on efficient patient processing in order to provide bed capacity. Not every hospital is like this, however. Some very small facilities might find that this particular model is too costly to initiate and maintain.

However, some form of integrated care, for any healthcare organization, can have a huge impact. Rapid admission processing and nursing assessment, error-free patient care and medication delivery, and efficient processes such as medication reconciliation can profoundly reduce LOS, drop readmission rates, and raise patient satisfaction scores. Better managing patient evaluations and assessments also helps reduce costs by enabling more efficient workload rebalancing. If the hospital can better understand patient needs, during more of their stay, it can more accurately assess staffing needs, too.

The Patient Centered Admission Team

In most hospitals, admissions are processed by a number of different providers acting independently of one another in a sequential order, often resulting in delays, errors, redundancy of effort, higher costs, and lower patient satisfaction.

Sequential processing requires that things be done in a very rigid manner to produce the lowest error rate. A well-known example of this is in the airline industry, where pilots go through a very rigid checklist prior to departure every single time. Healthcare is full of sequential processes, and for good reason, in most cases. An example would be the checklist process prior to surgery, in which, similar to an airline pilot, the surgeon follows a checklist to ensure he has the right patient, the correct surgical procedure on the correct side and so on. I myself recently underwent surgery on my tongue and they actually marked the outside of my left cheek since that was the side the surgery was going to be on. Obviously, I am glad the sequential process helped ensure my surgery was error-free, even though the process took time and resources to complete.

Parallel processing on the other hand is geared for efficiency. Multiple things can be done at the same time. Anyone who takes their car to an oil change shop can see a good example. While one person is taking your information, another is draining the oil and a third is under the hood checking fluid levels. Your car is in and out much faster than if you had changed the oil yourself, in a sequential order of tasks.

There are not many parallel processes used in healthcare because the multiple individuals involved work in separate, siloed environments. Pharmacists have their own process, as do ED nurses, physicians, technicians, and every other healthcare professional. Rarely do they work together in parallel. However, The Patient Centered Admission Team (PCAT) process is a parallel process specifically designed to improve care delivery and efficiency in the healthcare system.

Regardless of admission type and portal of entry, the admission process will typically involve the following providers, each of whom is responsible for a portion of every admission:

Physician—History and physical, orders

Nurse—Nursing Assessment, medication delivery

Pharmacist—Medication reconciliation, medication review, order review, MAR

Technician—Vital sign acquisition, weight, transport set-up, blood draw, EKG

In the majority of hospitals, a patient must wait for each task to be completed, one after the other, and hope that none of the providers or departments involved is having a heavy workload that day. Any delays cause the entire process to be delayed. Before instituting a PCAT, we measured the standard approach to admissions.

The following are actual findings from such a study:

  • (1) Full history and physical examination (H&P) 25 min
  • (2) Full admission orders 5 min
  • (3) Head to toe nursing assessment 60 min
  • (4) Medication reconciliation 15 min (varies depending on who completes)
  • (5) Production of an MAR 180 min
  • (6) Dispense of medications 60 min
  • (7) Report and handoff to floor nurse 10 min
  • (8) Report and handoff to floor provider 10 min
 
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